Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 82

1. Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first24 hours after surgery and cast application?

A) Mobilization of the child
B) Discharge teaching
C) Pain management
D) Assessment of neurovascular status

2. A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infants developmental progression?

A) She sits briefly alone with assistance.
B) She creeps and crawls.
C) She pulls herself to her feet with help.
D) She stands while holding onto furniture.

3. Children often experience visual impairments. Refractive errors affect the child - s visual activity. The main refractive error seen in children is myopia. The nurse explains to the child - s parents that myopia may also be described as:

A) Cataracts
B) Farsightedness
C) Nearsightedness
D) Lazy eye

4. A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?

A) Astigmatism
B) Hyperopia
C) Myopia
D) Amblyopia

5. An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

A) A tension pneumothorax
B) An asthma attack
C) Pneumonia
D) Pulmonary embolus

1. Right Answer: D
Explanation: (A) Mobilization is important but not absolutely essential. (B) Discharge teaching should be initiated prior to surgery as well as during the postoperative period. (C)Assessment and management of pain are necessary and high in priority. (D) Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application. This type of fracture is common in children. A high incidence of neurovascular complications exists with fractures near the elbow.

2. Right Answer: A
Explanation: (A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many infants can pull themselves to a sitting position. (B, C, D) This skill represents normal development.

3. Right Answer: C
Explanation: (A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens. (B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects. (C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D)Lazyeye refers to strabismus or misalignment of the eyes.

4. Right Answer: C
Explanation: (A) Visual images are blurred and distorted. (B) Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. (C) These symptoms are classic for myopia. (D) Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.

5. Right Answer: B
Explanation: (A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production.Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. (D)A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.

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